Ted R. Prins

Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience.

OBJECTIVES To present an 8-year clinical experience in the endovascular treatment of short-necked and juxtarenal abdominal aortic aneurysm (AAA) with fenestrated stent grafts. METHODS At our tertiary referral centre, all patients treated with fenestrated and branched stent grafts have been enrolled in an investigational device protocol database. Patients with short-necked or juxtarenal AAA managed with fenestrated endovascular aneurysm repair (F-EVAR) between November 2001 and April 2009 were retrospectively reviewed. Patients treated at other hospitals under the supervision of the main author were excluded from the study. Patients treated for suprarenal or thoraco-abdominal aneurysms were also excluded. All stent grafts used were customised based on the Zenith system. Indications for repair, operative and postoperative mortality and morbidity were evaluated. Differences between groups were determined using analysis of variance with P < 0.05 considered significant. RESULTS One hundred patients (87 males/13 females) with a median age of 73 years (range, 50-91 years) were treated during the study period; this included 16 patients after previous open surgery or EVAR. Thirty-day mortality was 1%. Intra-operative conversion to open repair was needed in one patient. Operative visceral vessel perfusion rate was 98.9% (272/275). Median follow-up was 24 months (range, 1-87 months). Twenty-two patients died during follow-up, all aneurysm unrelated. No aneurysm ruptured. Estimated survival rates at 1, 2 and 5 years were 90.3 +/- 3.1%, 84.4 +/- 4.0% and 58.5 +/- 8.1%, respectively. Cumulative visceral branch patency was 93.3 +/- 1.9% at 5 years. Visceral artery stent occlusions all occurred within the first 2 postoperative years. Four renal artery stent fractures were observed, of which three were associated with occlusion. Twenty-five patients had an increase of serum creatinine of more than 30%; two of them required dialysis. In general, mean aneurysm sac size decreased significantly during follow-up (P < 0.05). CONCLUSIONS Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm appears safe and effective on the longer term. Renal function deterioration, however, is a major concern.

Accuracy of FDG-PET–CT in the Diagnostic Work-up of Vascular Prosthetic Graft Infection

OBJECTIVES To investigate the diagnostic accuracy of fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) compared with computed tomography (CT) scanning and added value of fused FDG-PET-CT in diagnosing vascular prosthetic graft infection. DESIGN Prospective cohort study with retrospective analysis. MATERIALS Twenty five patients with clinically suspected vascular prosthetic infection underwent CT and FDG-PET scanning. METHODS Two nuclear medicine physicians assessed the FDG-PET scans; all CT scans were assessed by two radiologists. Fused FDG-PET/CT were judged by the radiologist and the nuclear medicine physician. The concordance between CT and FDG-PET and the inter-observer agreement between the different readers were investigated. RESULTS Fifteen patients had a proven infection by culture. Single FDG-PET had the best results (sensitivity 93%, specificity 70%, positive predictive value 82% and negative predictive value 88%). For CT, these values were 56%, 57%, 60% and 58%, respectively. Fused CT and FDG-PET imaging also showed high sensitivity and specificity rates and high positive and negative values. Inter-observer agreement for FDG-PET analysis was excellent (kappa = 1.00) and moderate for CT and fused FDG-PET-CT analysis (0.63 and 0.66, respectively). CONCLUSION FDG-PET scanning showed a better diagnostic accuracy than CT for the detection of vascular prosthetic infection. This study suggests that FDG-PET provides a useful tool in the work-up for diagnosis of vascular prosthetic graft infection.

Endovascular repair of acute AAAs under local anesthesia with bifurcated endografts: a feasibility study.

Purpose: To evaluate endovascular repair of abdominal aortic aneurysms (AAA) under local anesthesia in the acute setting. Methods: Between 1998 and 2001, 47 patients with an acute AAA were evaluated for endovascular repair after informed consent, provided they were in a stable, albeit hypotensive condition. The patients underwent urgent computed tomography to assess suitability for endovascular repair; 16 were eligible for stent-graft repair: 9 were frank ruptures and 7 were symptomatic aneurysms. Complications and outcome of endovascular repair were evaluated; mortality was compared to a contemporaneous surgical cohort. Results: Seven (23%) of 31 patients having a standard surgical procedure died in the study period compared to 1 (6%) of 16 patients undergoing endovascular repair (following conversion to surgery because of calcified access vessels). Twelve (75%) of the endovascular repairs were performed under local anesthesia; no complications with this mode of anesthesia were encountered. The median duration of the endovascular procedures was 110 minutes (range 75–240); median blood loss was 250 mL (range 100–2800 mL). Only 4 patients required blood transfusion, and only 8 patients required admission to the intensive care unit. There were 3 postoperative complications (1 ischemic colitis, 1 renal failure, 1 groin hematoma). During follow-up, 3 endograft patients received stent-graft extensions in uneventful procedures. Two patients died at 9 and 16 months from cardiac causes. Conclusions: This study demonstrates the feasibility and possible advantages of endovascular repair under local anesthesia in selected acute AAA patients. Further studies are needed to prove the advantages over open repair.

Stent fractures in the Hemobahn/Viabahn stent graft after endovascular popliteal aneurysm repair.

OBJECTIVE During the last decade, endovascular repair of popliteal artery aneurysms (PAAs) has become a valid alternative to open repair. This study analyzes the incidence and origin of stent graft fractures after endovascular repair, its impact on patency, and strategies to prevent fractures. METHODS Data of 78 atherosclerotic PAAs in 64 patients were gathered in a prospectively-held database from 1998 to 2009. All x-rays were reviewed to detect stent fractures. Only circumferential fractures were included for analysis; localized strut fractures were excluded. Clinical endpoints were circumferential stent fracture, occlusion, and clinical status of the patient. RESULTS Mean follow-up time was 50 months (range, 1-127 months). Fifteen circumferential stent fractures occurred in 13 (16.7%) patients. The majority of stent fractures (93.3%) were associated with the use of multiple stent grafts. At univariate analysis, younger age was identified as the only significant predictor for stent fracture (P = .007). The cumulative stent fracture-free survival was estimated at 78% and 73% at 5- and 10-year follow-up, respectively. The cumulative primary patency rate, defined as time to occlusion, was not different for the fracture group compared with the nonfracture group (P = .284). CONCLUSIONS The incidence of stent fractures after endovascular PAA repair is probably underreported in the literature. Stent graft fractures mainly occur at overlap zones and are associated with younger age of the patient. Fracture of the stent did not significantly influence patency of the stent graft.

Treatment of popliteal artery aneurysms with the Hemobahn stent-graft

Purpose: To report a prospective study to ascertain the results of popliteal aneurysm treatment with a self-expanding stent-graft. Methods: In a recent 3-year period, 21 patients (18 men; median age 67 years, range 52–82) with 23 popliteal aneurysms were treated with Hemobahn stent-grafts. Follow-up evaluation included duplex scanning, ankle-brachial index (ABI) measurements, and radiographic examination of the knee. Outcome measures were occlusion of the stent-graft and limb loss. Results: Technical success in placing the stent-graft and excluding the aneurysm was 100%. An additional vascular intervention was performed in the same session in 5 (24%) cases. In the other 16 patients, local anesthesia was used in 10 (63%). During a median follow-up of 15 months (range 2–37), 5 (22%) of 23 stent-grafts occluded, resulting in a cumulative patency of 74%. All occlusions occurred within 6 months after the intervention; 2 were successfully recanalized, and none of the 3 patients with persisting occlusion required an amputation. Conclusions: The results of this study suggest that endovascular stent-graft repair of popliteal artery aneurysms is feasible. Midterm patency rates are lower compared to traditional surgical repair.

Transcutaneous Port for Continuous Duodenal Levodopa/Carbidopa Administration in Parkinson's Disease

Motor fluctuations in Parkinsons disease (PD) can be reduced by intraduodenal infusion of levodopa‐carbidopa (Duodopa®) via percutaneous endoscopic gastrojejunostomy (PEG). We applied the transcutaneous soft‐tissue anchored titanium port (T‐port) in 15 PD patients with motor fluctuations; 7 Duodopa‐naive (non‐PEG), and 8 previously receiving Duodopa (former‐PEG). Motor scores (UPDRS‐III) and quality of life (QOL, PDQ‐8) were assessed at baseline and 6 month follow‐up. Six patients had local irritation shortly after implantation, persisting in one patient at 6 month follow‐up, which led to explantation. After having finished the protocol, four T‐ports were explanted in total. UPDRS‐III and PDQ‐8 scores improved moderately in the non‐PEG patients, but remained similar in the former‐PEG users. Two former‐PEG users developed polyneuropathy. No obstructions, retractions, or leakages occurred. Technical and hygienic properties of the T‐port were preferred by most patients. The T‐port seems to be suitable for most PD patients qualifying for Duodopa therapy, although local infection may lead to explantation during longer‐term follow‐up.

Fenestrated and Branched Stent-Grafting: a 5-Years Experience

Abstract Fenestrated stent-grafts aim at treating short-necked aneurysms. As a result of customized fenestrations, patency of vital side branches such as the renal arteries and the superior mesenteric artery can be maintained, whilst positioning the graft over these aortic side branches. Over the years, the technique has been refined. Results in a few experienced centers are good, with excellent patency rates of targeted side branches. Suprarenal and thoraco-abdominal aneurysms can only be treated by endovascular means with branched grafts. This can be achieved with fenestrated grafts, but with the use of covered stents through the fenestrations, or by fully branched grafts. Both options are feasible and present with specific advantages and disadvantages. This report gives an overview of our 5-years experience with fenestrated and branched grafts, and discusses the following aspects of the technique: indications, technical principles, results, and limitations.

Results of Endovascular Abdominal Aortic Aneurysm Repair with the Zenith stent-graft

OBJECTIVE To evaluate single center results of the Zenith stent-graft for elective abdominal aortic aneurysm repair. METHODS Data from all patients treated with a Zenith graft between March 1999 and December 2006 were retrospectively analyzed from a prospective database. Outcome measures were technical success, all-cause and aneurysm related mortality, late complications, and re-interventions. RESULTS A total of 234 patients were included, of which 216 were male. Mean age was 72.1+/-6.9 years. Mean diameter of the aneurysm was 60.9+/-10mm. Technical success rate was 98.3%. Thirty day mortality was 1.7%. Median follow-up was 26.9 months (range, 1-104). Overall survival was 92.2+/-1.8% at 1 year, 87.2+/-2.3% at 2 years, and 69.9+/-4.6% at 5 years. During follow-up, one aneurysm ruptured due to limb disconnection, which was treated by bridging stent-grafting. Re-interventions were performed in 9.2% of the patients, with 79% by endovascular means. There was no mortality related to re-intervention. CONCLUSIONS Endovascular abdominal aortic aneurysm repair with the Zenith device provides excellent results with a low risk for aneurysm-related death and rupture, and a low re-intervention rate in the mid-term.

Treatment of a ruptured thoracoabdominal aneurysm with a stent-graft covering the celiac axis

Purpose: To present a case of successful emergency endovascular repair of a ruptured, probably mycotic, thoracoabdominal aortic aneurysm (TAAA) with a stent-graft deliberately covering the celiac axis. Case Report: A 79-year-old woman with significant pulmonary comorbidity presented with a ruptured mycotic TAAA extending to the celiac axis. The aneurysm was excluded with a stent-graft soaked in rifampicin and deployed to deliberately occlude the celiac axis for effective distal sealing and fixation. The patient recovered well and was prescribed antibiotic treatment for up to 6 months. Conclusion: Endovascular repair of a ruptured TAAA may be a life-saving option. In emergency situations when poor distal anatomy is present, covering the celiac artery with the stent-graft should be considered.

Relocation of supra-aortic vessels to facilitate endovascular treatment of a ruptured aortic arch aneurysm

Minimally invasive surgery creates new options for patients having a very high risk for morbidity and mortality during conventional operations. A patient with a ruptured thoracic arch aneurysm and a very high comorbidity profile could be treated with these novel techniques. We report on a combined procedure including off-pump coronary bypass grafting, open relocation of the brachiocephalic and left carotid artery, and endovascular exclusion of the thoracic arch aneurysm.